Form 720MP Application for Lump-Sum Payment - Missing Participant

Locating and Paying Participants

e_Form720MP revised

Locating and Paying Participants

OMB: 1212-0055

Document [docx]
Download: docx | pdf

Application for

Lump-Sum Payment


PBGC Form 720MP

Approved OMB 1212-0055

Expires

Pension Benefit Guaranty Corporation.
P.O. Box 151750, Alexandria, Virginia 22315-1750

For assistance, call 1-800-400-7242



Plan Name: FX.PrismCase.CaseTitle.XF


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF


Date Printed: 01/30/2021



Date of Plan Termination: FX.PrismCase.DOPT.XF



INSTRUCTIONS: Use this form to request a lump-sum payment. As proof of your date of birth, enclose a copy of your birth or baptism certificate, or U.S. Passport. If you are a deceased participant’s spouse, enclose a copy of your marriage certificate if you have not already sent it to us. Please make sure that proof documents are legible before sending to PBGC. If you have questions about other documents we accept as proof, call our Customer Contact Center at 1-800-400-7242. Print clearly with blue or black ink.



1. General information about you


Last Name

First Name

Middle Name

Other Name(s) Used


Social Security Number

Date of Birth (Copy of Proof Required)

Gender

male




-



-







/



/






female


Mailing Address

Apartment / Route Number

City

State

Zip Code

Country

Province


Daytime Phone

Extension

Evening Phone

(




)




-





x





(




)




-







If you are the participant and worked after the date the plan terminated, what year did you stop working for the employer who sponsored your pension plan?

Year









CONTINUE








Application for Lump-Sum Payment Form 720MP, page 2 of 3


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name: FX.PrismCust.FullName.XF





2. Payment Election Please read the enclosed Special Tax Notice Regarding Non-Periodic PBGC Payments. Be sure you understand the tax implications of having PBGC pay the lump sum directly to you or to an individual retirement arrangement (IRA) or a qualified retirement plan.


Please elect only one option - A or B or C. If you do not elect an option or if you elect more than one option, PBGC will pay you according to option B.


A. Roll over my payment to an IRA or a plan – Send my entire payment, plus interest, directly to an IRA or a qualified retirement plan. I understand that PBGC will not withhold taxes from my payment.

































B. Pay me directly – Send the entire payment, plus interest, directly to me. I understand that PBGC will withhold 20% of the taxable amount of my payment for federal income tax.





C. Split my payment - Send some of the money, plus interest, directly to me, and send some directly to an IRA or a qualified retirement plan, as follows:



1. Send this much directly to me:


$






.


I understand that PBGC will withhold 20% of the taxable amount for federal income tax.





2. Send this much to an IRA or a qualified retirement plan.


$






.


I understand that PBGC will not withhold taxes from this part of my payment.

Note: the amount must be at least $500.






If you elected option A or C, complete Section D on page 3.






CONTINUE




Application for Lump-Sum Payment Form 720MP, page 3 of 3


Plan Number: FX.PrismCase.CaseIdNmbr.XF

Participant Name : FX.PrismCust.FullName.XF





Payment Election (Continued)


D. Rollover Information

Name of IRA or Plan:

Type of IRA or Plan:


Traditional IRA



Roth IRA


Qualified retirement plan


Account Number


Name of the Institution / Trustee

Daytime Phone


(




)




-





Mailing Address




City

State

Zip Code











-







3. Signature – Sign and date this application in the presence of a Notary Public. Knowingly and willfully making false, fictitious or fraudulent statements to the Pension Benefit Guaranty Corporation is a crime punishable under Title 18, Section 1001, United States Code.


I declare under penalty of perjury that all of the information I have provided on this form is true and correct.


SIGNATURE



DATE

To be completed by Notary Public witnessing your signature above:

Subscribed and sworn to before me this __________________ day of ____________________, Year______




Date My Commission Expires


Notary Public Name




City / County


State


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitlePayee Information Form_PBGC Form XXX
AuthorPBGC\IOD
File Modified0000-00-00
File Created2021-01-30

© 2024 OMB.report | Privacy Policy